A case presentation of a fatal dengue myocarditis showing evidence for dengue virus-induced lesion

Abstract

Dengue is a prevalent arthropod-borne viral disease in tropical and subtropical areas of the globe. Dengue clinical manifestations include asymptomatic infections; undifferentiated fever; dengue fever, which is characterized by fever, headache, retroorbital pain, myalgia, and arthralgia; and a severe form of the disease denominated dengue haemorrhagic fever/dengue shock syndrome, characterized by haemoconcentration, thrombocytopenia, and bleeding tendency. However, atypical manifestations, such as liver, central nervous system, and cardiac involvement, have been increasingly reported. We report an atypical and rare presentation of dengue disease marked by a dramatic and fatal cardiogenic shock due to acute myocarditis. Histopathological analysis of heart tissue showed several multifocal areas of muscle necrosis and intense interstitial oedema associated with clusters of virus particles inside the cardiomyocytes and in the interstitial space, providing evidence of a possible direct action of dengue virus on myocardium.

Fulminant dengue myocarditis complicated with profound shock and fatal outcome under intra-aortic balloon pumping support

“…Although cardiac involvement of dengue has been reported [2,3], there were only rare reports of fulminant dengue myocarditis, and no cardiac mechanical support was used in the literature [4][5][6]. We presented a case of fulminant dengue myocarditis finally leading to fatal outcome even under intra-aortic balloon pumping (IABP) support.…”

“…However, there were rare reports of fulminant dengue myocarditis [4][5][6][7]. Lee et al [4] presented a case of dengue myocarditis with acute pulmonary edema episode where the patient recovered by supportive care.…”

“…Lee et al [5] reported a case of fulminant dengue myocarditis where the patient finally died because of refractory ventricular tachycardia. Miranda et al [6] showed a case of fulminant dengue myocarditis with profound shock, which led to a fatal outcome. Nevertheless, there were no cases of fulminant dengue myocarditis with cardiac mechanical support device such as IABP or extracorporeal membrane oxygenation (ECMO) reported.…”

Cardiac involvement in dengue infection

“…Virus or RNA have been detected in various tissues, including kidney, heart, lung, and brain in deaths due to dengue [24,65,66]. It has been proposed that derangements of Ca 2+ storage in the infected cells may directly contribute to the causation of myocarditis [67,68].…”

Cardiac tamponade in a patient with severe dengue fever

“…Cardiac involvement in dengue is often limited and benign, but can lead to dengue shock syndrome, which can present as transient myocardial dysfunction 3,4 . In one fatal case of dengueassociated myocarditis, large areas of muscular necrosis and intense interstitial edema were directly associated with dengue virus on the cardiac muscle 5 .…”